A new trauma nurse's journal about being a "Real Nurse", life and all the stuff in between

Monday, October 8, 2012

IV Insertion Tips

A couple of days ago a reader asked me for some tips on IV insertion, unfortunately I was in the middle of a three day stretch and I wasn't able to get a post up in time. It got me thinking though and I began going over all the things that I have learned in the last few months that have made putting in an IV much easier for me.

So here is what I could think of, I hope it helps.

Feel, don't look.

I know every instructor has said this and it makes about zero sense, but trust me, this is one time in nursing that your eyes can lie to you. It makes sense that every new nurse (and even some seasoned ones) will go for an easily visible vein, but often these veins are very close to the surface and will blow easily, deeper veins are often stronger, less fragile veins.

Palpate veins with your fingers tips and feel around for a springy feeling vein. It will feel vaguely like pressing down on an under inflated balloon, it will "bounce" a little under your fingers. Avoid "mushy" or soft feeling veins, these can be more delicate and blow easier. Select the largest vein you can find, they are way harder to miss, you can use a nice large catheter and they are less likely to "go bad". No point in putting in an IV that only lasts a few hours.

Once you have a found a nice big, bouncy vein follow it up about an inch or two and make sure it feels pretty much the same all the way up. A hardened area can indicate a valve or sclerotic area that will not allow the catheter to advance. If you find one of these area's be patient and follow the vein further up or down until you find a nice stretch of clean vein.

Hold on!

Now that you found that vein, anchor that sucker! You went through all the time to find it now make sure it doesn't run away when you try to poke it. I hear a lot of people say that a patient has veins that roll, all veins do roll to a certain extent so hold em down!

Everyone does it a little differently

For really roll-y veins try stabilizing

between two fingers.

Spread your fingers wide and hold the skin

very taut.

OR

Anchor the base of the vein close to your puncture site.

Apply pressure and pull your thumb towards yourself

pulling the skin taut

The key to anchoring a vein is to apply pressure, so don't be shy about pushing down on your patient and to pull their skin nice and tight. Apologize and let them know the discomfort will only be for a few seconds, it's a way better option than having to poke them a second time.

Don't go deep!

It's tempting to puncture the vein at a 30 to 45 degree angle, especially if you have drawn blood a lot, then drop your angle and attempt to advance the catheter, don't do it! Going in on a steeper angle than 15 or 20 degrees increases your chance of going straight through the vein, and I find that when I drop my angle after a flash I flub the insertion almost 50% of the time.

An IV nurse I work with gave me these tips, go in at an angle that is only slightly steeper than parallel with the vein and then check for your flash. If you don't have one advance slightly at a slightly steeper angle. As she put it veins aren't that deep and your aren't drilling for oil.

Don't be shy

OK so you got a great flash, but as you advanced the catheter you lose it. Sound familiar? It happened to me over an over again until my friend the IV Nurse commented that I am "bashful" in threading the catheter.

What she meant is that when I was advancing the catheter I would do so slowly because I was worried about losing my IV. Problem was that my caution was what was causing me to lose my IV sticks. She reminded me that advancing a catheter quickly would not cause any damage.

What I learned to do it insert the IV and check for a flash,

then wait and see how well the flash chamber is filling.

When I see that the chamber is nearly full,

I am sure the IV is in the vein.

Now in one smooth quick motion I advance the catheter.

I know it sounds way too simple but honestly it has worked like a charm every time. Oh yes and don't worry, if there is a valve or sclerotic area that you did not find prior to inserting the catheter won't advance, promise.

I still have trouble with the advancing the catheter and pulling back at the same time in a swift enough motion as as not to lose my placement. The experienced RNs make it look so easy!

But I am gaining confidence with my starts, and as long as I don't have an instructor or other nursing standing over me making me to nervous, I have managed to get some successful IVs on some pretty tough sticks. Of course with that being said in the ED where I am, they always just go for the AC, which pretty much makes me angry... and I am not even a floor nurse yet! lol

Glad to hear that you are gaining confidence but hold on and don't get mad at the ED staff for putting most of the IV's into an AC. Let me enlighten you so you can direct that anger appropriately.

The AC is THE BEST vein to go for when you are in the ED for these reasons;

1) If you don't have any idea what further treatment the pt may get a 20g in the AC is important. If they are going to need a CT with contrast the ONLY IV you can use is a 20g (or larger) in the AC. This is because of how thick the contrast is, it needs a nice big vein, you'd blow a hand or forearm vein. Also contrast must be run in closer to the heart to circulate so the lowest point in the body you can run contrast through is the AC

2) The AC is the best place to run fluids into fast with less chance of infiltration. In the ED you slam fluids into people with drips wide open. If you go for a smaller vein like the hand or wrist your chances of infiltration go way up...and then you're going to be inserting a new one.

3) Antibiotics, the ED often gives the first dose and they are seriously irritating to veins. You know what makes me mad? Seeing a floor nurse run Vancomyacin through a hand IV. If Vanco infiltrates into the tissues it can be so caustic a pt could be in need of a skin graft. For the love of god please run that Vanco through a nice big vein like an AC. It will lower your rate of phelbitis at the very least.

3) Other drips like Levophed need a big vein, in fact they should really ideally be run through a central line, but when you don't have time to put on in and your job is to stabilize, again go for the AC. A nice big vein that you can run pressors for while you get that patient stable before you pop in a central.

4) Yes it is also the easiest vein to find especially when a patient is crashing. Remember a lot of other veins get soft when a persons BP tanks, the AC stays palpable even with a bad BP.

What I'm saying is that while it may drive floor nurses crazy to put IV's in AC's because as soon as the patient bends an arm the pump beeps, it's actually good and safe practice on the ED staff's part. There are a lot of reasons for things to be done in the ED that are different else where, it took me a couple of months floating to find them out. But don't hate on AC IV's, just remind your patient to quit bending that arm.

I have not yet gotten the chance to place IV's yet because I am only in my first semester of the nursing program, but I am so excited to start using the tips! I know that many in my class will benefit from these gems.

These are some excellent IV insertion tips! Honestly I think these tips are helpful to a nurse at any stage in his/her career. IV sticks can be tough and any new perspective can help.There are some more great tips here: http://bit.ly/1aqdpoG that are really helpful, especially to new nurses.

I could not agree with you more, one should feel for the vein. I remember thinking that if I saw a vein then I could use that one but I had such a hard time inserting the IV. Once I learnt to feel for the vein I was getting it every time really easily. I will have to try your method for keeping a hold of the vein once I have found it, it seems to slip away sometimes.